House calls are not a core part of my practice as a specialist, although I have made many.

In doing a house call, I think of driving up a snowy road to a decaying-but-loved farmhouse and moving next to a window's light to look at what might be cancer. I am always struck by contrasting feelings of attachment with the patient and family and isolation from the medical environment. Without doubt, seeing my patients in their home amplifies understanding of their challenges. Deeper understanding of their cultural and personal roots is placed front and center. (And, of course, that understanding is a great help, even if it sometimes makes clinical detachment difficult.)

For a doctor, it's unusual to have this level of immersion in patients' contexts on a routine basis. But for people who deliver care in the home -- the caregiver, the aide, sometimes the family -- it is their "normal." They see a developing stroke manifest by a slow degradation in clarity of speech, although it's hard to describe and hard to communicate. They see subtle changes in the nature of a wound that portend massive sepsis. But they are not given the tools or the structure to communicate these observations, hunches, and context effectively.

Medical hierarchy is both very deep, very entrenched, and often with caregivers and home care aides, seen as being at the "bottom." Because of the hierarchy, providers like aides, who primarily give care at home, are expected to carry out orders, not influence the course of care. So they're left with checkboxes and protocols, not tools to share their insight. Often checkboxes and protocols are designed to avoid mistakes, but instead have the unanticipated consequence of communicating nothing because there are not enough boxes to check.

The hierarchy has value in that a chain of command makes orders clear and accountability strong. However, complex situations demand a more complex flow of information. Not just orders from top to bottom, but information "uphill," too. And when information needs to flow uphill, the orderliness of hierarchy makes a strong barrier to responsive and personal adjustment and modification as a vital response to changing condition.

Beyond communication, we need to rely on collaboration where we take the best of everyone in the hierarchy and build a team and a plan. Teams change. Plans change. We need to accommodate, embrace, and adjust to the change.

So, to return to the title of this post, probably the loneliest and most solated work in healthcare is home health care. Changes are observed but it can be an almost impossible job to communicate those changes in the context of the hierarchy. When home monitoring sends a signal of weight change to a central station, that is lauded as a great breakthrough and it is. Then what? The caregiver in the home probably saw a change first and even knows the intervention that is needed. We need to recognize this and empower the change while keeping the entire team involved.

One more reason for doing what we are working so hard to do: getting access for the patient, collaboration for the providers, and use the interactions to teach those who follow us.

We're all trained to look for "best practices." If there is a best or better way to do something, we want to know what it is. Many times, though, the excellence of medical care depends on the patient and the context.

The field of Long Term Care is no different. Sometimes an assisted living facility works just right. Sometimes aging in place is the ultimate. Sometimes it's senior co-housing. What works best in Long Term Care is for each patient to have access to the kind of care that works best for him or her. People want and need different things.

That's also why we see this trend that the New York Times recently covered, of small residences that still have the medical and caregiving resources that many older people need. It's a balance of medical help that can only come from an institutional setting, with the human need for more individualized settings. For instance, Our Family Home is a small, home-style setting for groups of patients with Alzheimer's or dementia. And The Green House Project is a network of homes that are created to support patients' needs while also feeling like an individual house.

There are some important challenges with these models, though. Because the settings are more dispersed, for specialized care to be happen, patients will often have to travel to a doctor's office or a hospital. Or, the specialist will need to travel to multiple facilities to complete the rounds.

So what's the answer, when decentralized models are great but there are geographical challenges with access to care? Well, it's a pretty simple answer, actually. We believe that telemedicine platforms can allow less centralized, more intimate, more personalized housing solutions to be viable. By allowing healthcare collaboration across the continuum of care to occur -- on the schedule and in the location of the people involved -- these models become a lot more practical, even in complex medical situations.

These are 3 key ways telemedicine supports seniors in getting the Long Term Care that works best for them, even in decentralized models:

Telemedicine makes it so more people can be involved in care, while not interrupting "compassionate continuity."It is best for people to have continuity in the people who care for them. However, the complexity of many patient's conditions require nurses, aides, specialists, other specialists, and therapists to collaborate on a single case. A platform like iClickCare allows these people to contribute while also allowing the trusted aide to be the primary person in the patient's life.

Healthcare collaboration -- at a distance -- makes homecare more financially sustainable.If specialists have to make increasing numbers of house calls, because there is insufficient technology to allow collaboration at a distance, homecare becomes less viable. If these trends continue, we'll need to find ways for the people providing the home care to be supported by other medical providers, in efficient and effective ways.

If you're part of changing how Long Term Care happens, we want to help. You can download our free ebook on transforming Long Term Care here:

Photo used under Creative Commons rights from fairfaxcounty on Flickr.

Healthcare in the US is almost unfathomably complex. Plus, it's always changing, such that it can be very hard to notice trends in any useful way.

However, we are at an especially volatile and important moment in medicine, with the reverberations of the Affordable Care Act still playing out. Just in the past few weeks, I've noticed a few trends that I think every ACO, every hospital, and every medical provider should have their eyes on.

3 shifts in medicine that will probably impact you in the next year:

Insurers will be demanding "more" from providers and hospitals.On one hand, insurers are squeezed by higher-than-expected costs of the newly insured. Many are now requesting rate increase approval from the government. As the New York Times reports, "The rate requests, from some of the more popular health plans, suggest that insurance markets are still adjusting to shock waves set off by the Affordable Care Act." On the other hand, many insurers are merging, which gives them more leverage over hospitals and providers. The pressure to increase revenue and cut costs, combine with increased power from mergers may well add up to more demands on providers and hospitals.

Non-traditional care contexts are becoming the norm.Because of shifts in what is able to be reimbursed under the Affordable Care Act, there are new delivery mechanisms being pioneered. For instance, there is a current boom in diet clinics, due to ACA reimbursement for obesity consultations and treatment. It's likely that as care outside of doctors' offices increases (with other medical providers being the ones actually interfacing with the patient), healthcare collaboration (especially using telemedicine tools) will become more important. Collaboration will need to happen more, and across the spectrum of care, in order for patients not to fall between the cracks.

Home care is a growing segment of medicine, and we're (mostly) not doing it well.Data is beginning to suggest that there are more homebound people than ever before, and they're sicker. Plus, there are more caregivers who are older family members and need support themselves. This type of dynamic means that medical providers are responding, and finding ways to provide care at home. For instance, there is a growing group of geriatrics practices that make housecalls. And if those housecalls have to be made by specialists because there is insufficient technology to allow collaboration at a distance, that's going to be unsustainable. If these trends continue, we'll need to find ways for the people providing the home care to be supported by other medical providers, in efficient and effective ways.

For decades, medical providers had the luxury of ignoring macro trends. These days, however, I think that we ignore these dynamics at the peril of ourselves, our practices, and our patients. For us to act with wisdom, sustainabily, and in service of good medicine, we must act with these things in mind.

And really, that is more of a privilege than a burden.

To learn how iClickCare can help you adapt to these shifts, click here:

It goes without saying that in the 3+ decades that I've been a doctor, I've seen a lot of changes in the medical profession. Many of these changes have been difficult, of course -- plummeting time with patients, ludicrous paperwork, and illogical financial incentives, among them.

From time to time, however, I see big changes in medicine that are deeply positive. The most powerful and progressive changes are happening through:

Thoughtful integration of simple "good medicine"

Alignment with current political and financial realities

Creative use of existing technologies.

The "return of the house call" is one of these fantastic trends. For a long time, it has looked like the house call went the way of the doctor's bag -- a nice idea but not something that fits our current reality. Recently, however, there has been a resurgence in house calls and home care for everything from palliative care to wound care to concierge medicine.

The return to medical providers visiting patients at home is supported by common incentives and the current political climate. For instance, the Affordable Care Act penalizes readmissions within 30 days of discharge; integrated home care is seen as one way to decrease readmissions and improve outcomes. Also, a focus on a "fee for performance" rather than a "fee for service" model, and an overall push to cut costs, has encouraged the "house call" approach. Finally, as the New York Times reports, "Home care is generally cheaper than hospital care, and for more than a decade, government programs such as Medicare and Medicaid have worked to create incentives for hospitals to switch to less-expensive treatment."

Because home care is removed from the traditional hospital setting, medical collaboration is crucial to successful home care.

For instance, a 2007 study, by Dr. Richard Brumley and colleagues, found that palliative care patients who received in-home interdisciplinary care were less likely to visit the emergency room or be admitted to the hospital than those receiving standard home care. This resulted in lower costs. For house calls and home care to really work, they need to incorporate providers across specialities and across the continuum of care. Providers must collaborate because it is not efficient for every provider to visit the patient at home, but a home visit can be a crucial part of an integrated approach. And telemedicine is the key for this kind of medical collaboration to be effective, cost-efficient, and time-sensitive.

We've found that house calls and home care are especially powerful when the following components are in place:

A look back at the past, can help us with the Now. Right now, the "Future of Healthcare" is a big conversation. The Supreme Court is about to hand down a decision on healthcare, but the train has left the station. Years before the internet, at the birth of computing, there was considerable controversy about the control of computing. Large companies were designing large computers for large jobs. Steve Wozniak and his colleagues changed all of that. Now we have small, powerful and even smaller, computers for everyone, everywhere. Control of the internet was next. Like telephone, radio, and TV before it, large companies and government tried unsuccessfully to control and centralize development. The discussion about healthcare is very similar. Dave Chase, our colleague in the NY Times report, discusses this in TechCrunch, entitled "Supreme Court Decision On Obamacare Has Little Relevance To Healthcare Disrupters."

At the ATA 2012, some special Woz quotes were caught on iPhone VIDEO even though they were omitted from the ATA Highlights. You can hear again his wonderful encouragementfor the entrepreneur, his talk about hard work and passion, his recommendation to do what one cares about and feels is important, not just do business.

Steve further said…”I love all the little devices that hook up to my iPhone. I’m a gadget guy. You know, I probably wouldn’t get a blood pressure thing at home and take readings and write them down. But heck, when I take a reading and it’s automatically on my iPhone, I can show it off, I love it.”

When Dr. Harris asked him specifically about telemedicine and mHealth, his shout out for iClickCare was a thrill because he mentioned iClickCare, and iClickCare alone, on the stage at the ATA 2012 in front of 5000 of our closest friends! He even volunteered a move to Alaska to reap some of these benefits of telemedicine.

In total, Steve Wozniak is a generous and appreciative individual whose life has made, and is making, the world a better place.

ClickCare believes that, especially in light of the pending Supreme Court decision on healthcare, real change occurs through innovation and collaboration. What are your thoughts?

Accountable Care Organization, Care Coordination, Pay for Performance, Patient Centric Care, Coordination of Care, and so much more. It is all ready here. See the difference.